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HomeMy WebLinkAbout1324A � WORKERS'COMPENSATIONDECLARATION epai ��er�nn� �C1R PFRMIT � � hereby affirm that I hove n certifi<nte of conseN fo self ^• • "v�""'�'� • �'� ` `�'"^" sure,or a certifimte of Workers'Compensafion i�5��a��e, HEATING - VENTILATING - AIR CONDITIONING o certified capy��hereof(Gec 380Q Lab.C.) 76A36nC � CF-818(REV.1 D/81) � _,P�olicy No. Company � Certifietl copy is hereby furnished. 'COUNTY OP LOS ANGELE5 BUILUING AND SAFETY � � Certified copy is filed with ihe county b�ilding inspeo FOR APPLICANT TO FILL IN aui�oiNG � . ��� J' � tion departmeni. ADDRE55 _ f �PRINT OR TYPE ON�YI � Date Appliarnt . tOCALITY �� NO. TYPE OP APPLIANCE OR EQUIPMENi FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � COMPENSATION INSURANCE CROSS Si. � (This section need noT be compieTed H Tbe work involved by ABSORPTION UNIT,BTU oisteict No. PFocesseo ev � ihe permit(s for one hundred dollars(SI00)or less.) �� � I certify that in the periormance of ihe work for which this AIR HANotING UNIT,CFM permit is issued,I shall nof employ any person in any manner .� so as to become subjeci to the Workers'Compensation Laws. BOILER,BTU �� � nvPaovnis onre ��Ns aua�s si�NarueF v//�� �`�"� �/� COMPRESSOR,BTU ROUGH � �`Date_1�_—/�Applimni , _ NOTICE TO APPllCANT: If, affer making ihis Certifimte of vEN71tATION SVSTEM FINAL •�- Exemption, you shauld become subject to ihe Workers' � Compensation provisions of the�Labor Code,you must forfh- EVAPORATIVE COOIeK 1 V LIDATIOPF� ,�'���,r=- with mmply with suth provisions or ihis permit shall be �{� �l,�j �C� ,�.� � deemed revoked. FURNACE: Fnu cqnwTv � F -7 LICFNSED CONTRACTQRS DECLARATIDN FIOOR _BTU �-��`��, 3�� t r�L_���`F� �� I hereby affirm fhat�am licensed under provisions nf Chapter 9 HEATER: SUSPENDED_ UNIT— ���r`.�.,`�..�-� -{cor:m?ncing with Sec±ion 7000)�of Division 3 of the Business � WA�� ±� -___.___ and Professions Code,and my license is in fuli torce and effect. 9, � License Number Lic.Class � � � � Contrac�or Datc � ❑ °a.f � i am exempt under Sec. � Plcn check fee B.&P.C.for this.eason PERMIT ISSUING FEE$ �'J .5� '' � Date' � Signotu�e TOTAI FEE U 1 � OWNER-BUILOER DECLARATION Ptan,'CHECK.4PPLICANT I hereby affirm that I am exempt from the Coniractor s Licensa . � � iaw for the following reason (Section 7031.5;8usiness and � NAME . . Professions Code): � laDDRE55" � I, as owner of the property, or my empioyees with � � `�wages as their sole cnmpensation,will do the work and _____a � ` ' g�'1'�� , the slruc}ure is not in?ended or offered for sale(Section CITY TEL NO. �T„_,,,o�,� 7044,Business and Professions Cade). - �`}� g � � ��: � OWNER J ❑ I,os owner of the property,dm exclusively coN«�cting � t a s��-U�v with ficensed contractors ro consir�ct the project(Seo � M��� . � ADDRE55 yyy tion 7044,Business and Professions Code). � ���� " e � s,',^,L,��%� � CONSTRUCTION LENDING AGENCY - GTY������ � TEL NQ �,� I hereby affirm that tf-�ere is a mnstruction lending agency for �, (�Q�t r--'''�-; ihe performance of the work for which this permii is issued CONTRhCTOR (Sec.3097,Civ.C.). ADDRESS Lender's Name ___ . CITY TEL NO. - Lender's Address - STA1[ LIC. I certify Iha?I hav=read this application qnd siafe fhat ihe IICENSE NO: CLASS � � � � above information is corred.I ogree to comply with a�l County _ ordinances and State laws relating to building consh�ction, { and here 'ufhorize representatives of ihls County fo enfer i upor�th ove-men on ro ry for inspedion purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE � � Signarure of Appllmnt or Agani Dote 1 � . E � :� � w � - � � , � 1 � ��1 � � � � � � � � � � � � r � � � � � I ' J:: ' '� � -' .- 1 � � , .-� � ��� 'p m � c�i m � cn�1 c � . . '. � ., �' :Q O Q � O � . , � C =• 7 � ' . , �5 I��❑ .� � W� � ro C� 6 _ . . .� � � p � �. . _,. o p T ¢2 u �„ r-, (� . � a 3 ' o, s ,�^ �-1 fl ", � n� � °p' Q � � 4. !Z N � `p cJ� {] ��� j T. J �.1 G LJ w � LT .{;�O'Q_�'fl �-"B8 p_ ' . „y. �� Q � [� ^.. 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